Treating Alcohol Problems in the Context of Other Drug Abuse.

People seeking treatment for alcohol problems frequently abuse other drugs as well, such as tobacco, cocaine, marijuana, methamphetamine, and opiates. The problem of polydrug use raises important issues for treatment providers. A person who abuses multiple drugs may have a more difficult time stopping drinking and a higher risk for relapse to alcohol use after treatment. Conversely, a person who successfully stops drinking may offset this achievement by substituting another drug for alcohol. Successful treatment must take into account both alcohol- and drug-related issues, with particular emphasis on assessment, motivation, treatment design, and outcome evaluation.

P eople who meet alcohol abuse than other people (18 versus 3.5 per attempting to selfmedicate a psy or dependence criteria 1 often cent) to meet the criteria for another chological disorder (Jensen et al. 1990). use, abuse, or are dependent on druguse disorder (Helzer and Pryz The problem of polydrug use raises other drugs as well. The "pure alco beck 1988). important issues for both alcohol treat holic" represents the minority in clin People with alcohol problems are ment programs and providers (Weisner ical settings, where the majority of more likely to use a variety of other 1992b). The use of other psychoactive patients engage in polydrug use. Ac drugs, including tobacco, cocaine, mari drugs, such as tobacco or marijuana, cording to one recent study, more than juana, methamphetamine, and opiates may increase a person's risk for relapse 60 percent of men and women present (for further details, see box, p. 120).
to alcohol use following alcohol treat ing for treatment of alcohol problems Compared with individuals who expe ment. Outcome studies indicate that used another drug at least weekly rience only alcohol problems, polydrug among people in treatment for alcohol (Caetano and Weisner 1995), and users are likely to be younger and to related problems, those who use other other studies have reported similarly have more severe alcohol and other drugs exhibit less change in their high rates of multiple drug use (Weisner drug (AOD)related problems (Caetano drinking habits (Brown et al. 1994;1992a). Even in the general population, and Weisner 1995; Hesselbrock et al. Rounsaville et al. 1987). One reason for people who are alcohol dependent have 1985). In an attempt to understand the this finding may be that polydrug use been found to be five times more likely high rate of comorbidity, some re also tends to be linked to personality searchers have suggested that alcohol behavioral types that are more resistant 1 In this article, the terms "alcohol abuse," "al use disorders and other druguse disor to change. Another important issue for cohol dependence," and "psychoactive drugs" ders may share a common genetic (Jang clinical (Miller and Brown 1991) or that people drug use is not addressed, a reduction in Fourth Edition.
using alcoholdrug combinations are alcohol use may be offset by an increase in other drug use. Furthermore, treat ment for polydrug use may require dif ferent emphases or approaches than does treatment for alcohol problems alone. That alcohol and other drug use can be considered a "dual diagnosis" reflects, in part, the fact that histori cally, both the treatment and research programs for these two problems de veloped separately and in relative iso lation from each other. This separation has been reflected in treatment systems, in selfhelp groups (e.g., Alcoholics Anonymous versus Narcotics Anony mous and Cocaine Anonymous), and even in the scientific journals that pub lish clinical research findings. However, whether people initially seek treatment for alcohol or for other drug problems, they are likely to be polydrug users. Consequently, treatment must focus on both alcohol and other drugrelated problems (Brown et al. 1994). This finding presents some unique chal lenges for alcohol treatment providers and others interested in elements of treatment including assessment, moti vation, treatment design, and outcome evaluation. This article reviews these issues by addressing polydrug use in people with alcoholrelated problems.

Polydrug Use
Because of the high rate of comorbid ity, people evaluated for alcoholrelated problems also should be screened and carefully assessed for other drug use and related problems. Although addi tional screening does lengthen the as sessment process, failure to gather drugspecific information is a serious omission. The first step in assessment is to consider each drug a person uses, whether or not its use currently meets abuse or dependence criteria. This gives a better understanding of alco hol's interactions with other drugs in the person's life. For example, the use of drugs other than alcohol may trig ger alcohol use, and the presence of one drug in the body can dramatically alter or intensify the effect of another drug. An effective way to assess patterns and interrelationships in polydrug use is to reconstruct past AOD use on a daybyday or daysper month basis (Miller 1996).

Consequences
A second step in the assessment process is to evaluate the adverse consequences (as well as the potential consequences or risks) of AOD use that have occurred during the person's life, some of which may be quite drugspecific. Legal and health consequences, for example, vary substantially from one drug to another. Routes of drug administration also are an important consideration (e.g., risk of HIV exposure is related particularly to needle sharing). Finally, signs of in toxication and chronicuse symptoms should be assessed for various classes of drugs-for example, paranoia, hal lucinations, and repetitive movements or actions (i.e., stereotypes) associated with cocaine and other stimulants.
Knowing of the mere presence or absence of any impairment, however, is less informative than understanding the specific nature and extent of AOD use consequences in a person's life. Risky or harmproducing use is the defining criterion for an AODabuse diagnosis (American Psychiatric Asso ciation [APA] 1994).
Some assessment instruments have confused consequences with other dimensions, such as dependence symp toms and helpseeking behavior. Sur veying specific adverse consequences is one assessment option, although it is complicated by the person's own per ceptions of whether his or her problems are in fact the result of AOD use. A more general assessment of areas of life functioning (e.g., employment, legal, and interpersonal areas), such as that provided by the Addiction Severity Index (McLellan et al. 1990), is another alternative. (For additional approaches to assessing consequences and other dimensions mentioned here, see the re view by Miller and colleagues [1995a], which includes methods applicable to both alcohol and other drug use.)

Dependence
Like AODrelated consequences, AOD dependence is a continuum rather than a dichotomy. Thus, a third step in as sessment is determining the severity of the person's dependence on each drug used. Pharmacological issues of cross tolerance and codependence are im portant clinical considerations when assessing dependence severity. Cross tolerance is the phenomenon whereby once a person has established tolerance (i.e., relative insensitivity) for one drug, he or she also may exhibit tolerance for drugs from the same or similar classes. A person with a highly established tol erance to alcohol, for example, also may exhibit elevated tolerance to certain tranquilizers, sedatives, and anesthetics, thereby requiring larger doses of these drugs to obtain the desired effect.
The term "codependence" properly refers to simultaneous addiction (i.e., AOD dependence) to two or more drug classes. When a person stops using one drug, such as alcohol, he or she may experience a withdrawal syndrome specific to that drug. This may motivate the person to resume using the drug or to use another drug of a separate class (e.g., benzodiazepines) for which he or she has a crosstolerance. Acute alcohol withdrawal syndrome, for example, tends to begin within 24 hours of ab stinence and to run its course within approximately 1 week. Withdrawal syndrome from other drugs, however, may not begin until after 1 week or more of abstinence. Thus, a person who is dependent on multiple drugs can experience sequential or overlap ping waves of withdrawal, which can interact with each other in intensifying and dangerous ways. Consequently,

DRUGS OF ABUSE
Drugs of abuse-whether they are banned, controlled (e.g., prescribed by physicians), or legal-produce a "high" or altered state of consciousness in people, and all are at least psychologically, if not physiologically, addictive. Here the similarities end, however. Different drugs produce a wide range of effects, and each can be categorized based on its overall effect (e.g., whether it is a stimulant or depressant). Following are de scriptions of some commonly abused drugs classified according to the effects they produce: • Depressants-Alcohol, sleeping medications (e.g., barbiturates), benzo diazepines (e.g., Valium ® ), and antianxiety drugs (i.e., minor tranquiliz ers) produce depressant or anesthetic effects by dampening the activity of brain tissue responsible for excitation, or stimulation. They also are capable of reducing pain (i.e., they have slight analgesic properties).
• Stimulants-Cocaine, amphetamines, and many weightloss drugs (e.g., methylphenidate, or Ritalin ® ) produce stimulant effects through a variety of mechanisms in the brain. Caffeine and the nicotine in tobacco are less potent stimulants.
• Narcotic analgesics-Opiates, such as opium, morphine, codeine, and heroin, produce painkilling effects in the body. Opiates are medically important because of this property but are subject to abuse as a result of it. Narcotic analgesics also produce drowsiness, cause mood changes, and, at high doses, affect mental functioning.
• Hallucinogens and Marijuana-Marijuana (i.e., cannabis); LSD (lyser gic acid diethylamide); natural hallucinogens, such as mescaline and peyote; and related drugs, such as PCP (phencyclidine), produce changes in a user's level of consciousness and can induce hallucinations, or visual illusions (for marijuana, this effect only occurs at high doses). Most of these drugs (except PCP) also have adrenalinelike effects on the body. dependence assessment can be a critical measure in avoiding health threatening situations.

Functional Analysis
A fourth step in the assessment proc ess is determining why the person engages in AOD use. A detailed eval uation of the antecedents, behaviors, and consequences associated with a particular behavior such as drinking (Meyers and Smith 1995), a process called functional analysis, helps to answer this question. For example, a person may be especially likely to drink excessively in the presence of certain people, when engaged in partic ular activities, or in specific locations, and drinking may result in rewarding consequences. When multiple drugs are involved, a separate functional analysis should be conducted for each drug, because situational factors (i.e., people, places, and activities) affect ing AOD use may differ across drug classes. A person may use one kind of drug when feeling depressed or anx ious, and another type when feeling bored. Discovering the functional re lationships among the drugs used can make it easier to identify the person's "primary" drug of abuse as well as provide clues on where to focus first in treatment. For example, functional analysis may reveal that a person's alcohol use and cocaine use typically occur together, with drinking always occurring first, setting the stage for cocaine use. Alcohol may be used to enhance the effects of some drugs, such as opiates, or to "take the edge off" other drugs, such as methamphet mine. More generally, functional analysis of polydrug use can identify cues and triggers associated with AOD use, along with sources of reinforce ment for maintaining the use. Such in formation can be particularly useful to treatment providers when planning change interventions (discussed below).

MOTIVATIONAL ISSUES
It is important to understand a person's motivations both for using alcohol and/or other drugs and for seeking to change such behavior. Strengthening the person's commitment to change constitutes an important first step in treatment and can substantially im prove treatment outcomes (Bien et al. 1993;Brown and Miller 1993). Moti vational issues may be particularly important when screening identifies AOD users who have significant but less severe problems and dependence. Employee assistance and judicial sys tem programs, referrals of alcohol or drugimpaired drivers to treatment, and the widespread use of urine analysis for drug screening allow earlier identi fication of AOD users. People in this group usually are less motivated, how ever, when appearing for evaluation and treatment services. When multiple drugs are involved, the person's motivations for use and for change may be quite drugspecific. People often are motivated to change their use of some drugs but not others, and they may have flawed perceptions of which drugs are their "problem" or "primary" drugs. Thus, comprehensive assessment should include evaluation of a person's motivation for change with respect to each drug used. For ex ample, a person may be concerned and feel out of control with regard to co caine use, somewhat aware of problems related to alcohol consumption, and unconcerned about frequent marijuana use. Such perceptions and motivations may need to be an early focus of treat ment (Miller and Rollnick 1991).
Treatment goals are another impor tant consideration, and these likewise may be quite drug specific. Because of the value of abstinence in recovery, treatment programs sometimes en dorse immediate abstention from all psychoactive substances as the only viable treatment goal. Even when a person is only abusing a single drug, the likelihood of "slips" or "relapses" is high, and for people abusing multi ple drugs, the risk of relapse may be even higher (e.g., Rounsaville et al. 1987). The expectation of permanently ceasing all drug use may seem at first overwhelming or impossible to achieve, and early violations may be interpreted as evidence of failure. Insistence on immediate acceptance of universal ab stinence may result in poorer treat ment compliance (SanchezCraig et al. 1984). A perspective that values progressive steps in the right direction (Marlatt et al. 1993) is consistent with research findings indicating that im provement often consists of a series of such steps interspersed with setbacks (Miller in press). Although the ulti mate goal still may be cessation of all drug use, treatment may begin by tar geting the person's areas of greatest risk and concern. For example, injec tion drug use might be targeted first because of its highrisk potential. Con sequently, a change from intravenous to oral drug use would be regarded as a positive step. This perspective is an un derlying assumption in drugsubstitution approaches, such as methadone main tenance. The person's own motivation also is a crucial guide in following a stepbystep approach. At a given time, a person may be ready to stop using one drug completely but only willing to taper off the use of another. Over time, the person can establish further goals and take additional steps toward a drugfree lifestyle.

TREATMENT ISSUES
Many similarities exist among treat ments for different AODuse disorders.
Polydrug use can be treated directly through various strategies, including sobriety sampling, selfcontrol train ing, and pharmacotherapy. There are also, however, unique aspects of treat ing alcohol problems in the context of polydrug abuse. As previously men tioned, using one drug can increase a person's likelihood of using another drug. This phenomenon may occur For people abusing multiple drugs, the risk of relapse may be even higher.
simply because two drugs have been paired so often (as in the case of smok ing and drinking) that the use of one drug serves as a cue for the other (for a more detailed discussion of cue re sponses, see the article by Shiffman, pp. 107-110). Alternatively, one drug may be used to modulate or enhance the effects of another drug. For exam ple, alcohol may diminish judgment and inhibitions against using other drugs, such as cocaine. The abstinence violation effect of relapsing to one drug may similarly set off a chain reaction of polydrug use. Such interactions illustrate the difficulty of treating only one drug problem in the context of polydrug use. Although in the past people often were dissuaded from trying to stop smoking while recover ing from alcohol problems, it may be more effective to address druguse problems together, and failure to do so may make recovery even more difficult (Bobo et al. 1995). As discussed earlier, the proper sequencing of change and efforts that seek to decrease harm is one of the challenges of treating polydrug use and its related problems, and much remains to be learned in this area.
So how does the treatment of poly drug abuse differ from treatment for alcohol problems alone? Certainly spe cific pharmacotherapies must be con sidered. Although drug substitution therapy, such as prescribing benzodi azepines, is almost universally rejected in treating alcohol problems, it is widely accepted as a treatment component for tobacco or opiate dependence (e.g., nicotine substitution or methadone maintenance). Naltrexone blocks the effects of opiates, and current evidence indicates that it also may suppress al cohol craving and binge drinking. In cases in which cocaine use is triggered by drinking, disulfiram may help de crease the use of both by blocking alcohol use. A variety of psychiatric medications currently are being tested as adjuncts in treating AOD abuse and dependence. Familiarity with and open ness to drugspecific pharmacothera pies will be important in addressing polydrug abuse; however, this approach may create problems in alcohol treat ment programs that promote a totally drugfree orientation.
Treatment setting also may play a role. For alcohol problems in general, little evidence exists to support a dif ferential benefit from more intensive or restrictive settings, such as inpatient programs, versus outpatient treatment (Institute of Medicine 1990 and Brad ley 1994). Although drugdependence treatments have a long history of using residential therapeutic communities, it remains to be determined whether polydrug use is more effectively (and costeffectively) treated in inpatient or residential (nonhospital) programs than with outpatient services.
Even when residential programs are used, the person ultimately is likely to return to the general community and face the challenges of coping there. In this setting, the absence of positive coping skills appears to predispose individuals to relapse, and alcohol treatment outcome research strongly supports therapies that teach effective coping strategies (Miller et al. 1995b).
Various skillstraining treatments have been tested with success. One exam ple, the "community reinforcement approach," is an integrated program to help people improve coping skills and establish a rewarding drugfree lifestyle (Meyers and Smith 1995). This program has been tested in both inpatient and outpatient settings and found to be effective in treating alcohol, cocaine, and heroin dependence (e.g., Higgins et al. 1993). For polydruguse prob lems, it may be useful to encourage patients to acquire skills and make socialbehavioral changes that will support a drugfree lifestyle rather than to focus exclusively on suppres sing drug use.
Finally, there is value in having a coherent conceptual model to guide therapeutic intervention. People with polydruguse problems typically expe rience a considerable amount of chaos in their lives as well as a pervasive pat tern of life problems. A reactive style of counseling that focuses on weekto week situations and crises may yield little longterm progress. Instead, the authors have found that an organized therapeutic perspective is most useful, including a longterm outlook on goals and a systematic plan for moving to ward them. When offered in the context of a supportive and empathic counsel ing style, such a structure can impart in the patient optimism and confidence in longterm change despite short term calamity.

OUTCOME ISSUES
Various special issues merit consider ation when evaluating the outcome of treatment for polydruguse problems. The simplistic notion of "relapse" im plies that people are always in one of two discrete and mutually exclusive states: success or failure, abstinence or unbridled use. Even when the treat ment focus is a single drug, such as alcohol, this type of binary thinking is inadequate. The outcome of success ful treatment is less often sudden and permanent cessation; more often, re covery is a process of longer spans of abstinence that are interrupted by ever shorter and less intense periods of use (Annis 1986;Marlatt and Gordon 1985;Miller in press). This is partially cap tured in the idea of a "slip," which is by definition some period of use that does not constitute a "relapse." Although extreme examples are clear enough, the defining characteristics of a relapse are elusive, even for a single drug.
When multiple drugs are involved, outcome evaluation becomes even more complex. Although evaluation studies commonly have examined treatment effects on one "target" drug, this approach has clear limitations. From a holistic perspective, a person may not experience a positive outcome if the suppression of alcohol consump tion is offset by new or increased use of another dangerous drug, such as crack/ cocaine, heroin, or tobacco. Therefore, alcohol treatment programs should be evaluated based on outcomes of other drug use as well as alcohol use. Several outcome evaluation options exist, in cluding the previously mentioned day byday reconstruction of drug use. The frequency (i.e., the number of days per month) with which a person uses each drug provides a simpler index. Although quantity of use often is difficult to estab lish for drugs other than alcohol and tobacco, the amount of money spent on the drugs or the approximate street value of the drugs can provide at least a crude index of consumption volume. Changes in negative consequences of drug use also may prove useful as a relatively simple outcome measure (Miller et al. 1995a).
Finally, a binary classification of relapse and remission may not reflect the complexity of polydruguse out comes. Some therapeutic approaches, for example, may affect only the use of one target drug, whereas others may exert more general suppressing effects on psychoactive drug use. The longitu dinal sequence of change in successful recovery also may be informative, as evidenced by current research indicat ing that smoking cessation is associated with more favorable alcohol treatment outcomes (Bobo et al. 1995).

CONCLUDING REMARKS
Many of the people who seek addic tions treatment experience difficulty with both alcohol and other drugs, and treatment programs are being increas ingly called on to address a spectrum of drug problems. An organized pro fessional perspective will aid those clinicians who simultaneously address polydruguse problems to better un derstand the interrelationships of drinking, drug use, and the larger bio psychosocial context in which drugs are used. The prevalence of substance abuse among those seeking medical care further warrants close integration of AOD assessment and services with primary health care (Barry and Flem ing 1994).
In treating polydruguse problems, professionals versed in stateoftheart alcohol assessment and treatment will find much that is familiar. Although different drugs have some unique ef fects, risks, and consequences, there are more similarities than differences in assessment challenges and effective treatment approaches.
It seems likely that the addictions field and, ultimately, the quality of care will be strengthened by integra tive efforts. It is difficult to develop sound treatment programs without a good understanding of the condition to be treated, and clearly the patterns of AOD problems change within popula tions over time. Rather than develop ing isolated methods for assessing one drug, the addictions field may benefit from understanding how alcohol, to bacco, and other drug use interact in people's lives (Fertig and Allen 1995). Likewise, rather than merely studying the effects of treatment on the use of one drug, the field may grow by devel oping treatment strategies that exert a more general impact on polydrug use and related problems (e.g., Bobo et al. 1995). Such efforts may enable re searchers and clinicians to step back and develop a larger perspective on the ways in which multiple druguse re sides in the psychology, biology, and sociology of human nature. ■